Fever, Fever Burning Bright

Sherlock Holmes reclined in his chair, eyes glazed from days
of inactivity . Our apartment door at
221B Baker Street burst open. A young
and strikingly beautiful woman glanced about our sitting room. “Mr. Sherlock Holmes?” She looked at me. I pointed her to the lounging , lanky
figure. “Help me, please Mr. Holmes,”
she cried out, “my child has been burning up with for one week and three
physician visits have yielded
nothing. My daughter is sinking,
I feel it. Please help us, if you are
able.”

“If?” Holmes frowned and motioned the distraught woman to a
chair and offered her a cup of tea.
“Refresh yourself with a spot of Earl Grey, then let us proceed with the
facts and without the histrionics, if you please.”

She took a sip of tea, a deep breath, and launched into her
daughter’s story

STORY

“My 17 month old daughter was in the peak of health until
one week ago today when she seemed less active then usual and had an axillary
temperature of 101.5 degrees F. She
seemed to rally the next morning, but by the evening, her fever returned at 103.3
degrees. She refused to eat dinner, but
welcomed liquids. I gave her Tylenol
with slight improvement in the fever. I
took her to the clinic the next day and was told, after a thorough exam, that
she had a virus and to keep using Tylenol or Motrin as needed. My baby had no nausea, no vomiting, no
diarrhea, no rash, no exposure to animals, and no sick contacts. She stays with me throughout the day and
night. I returned to the clinic on
Monday, following the weekend, because she continued to have fevers on a daily
basis. Once again, no source was found
for the fever and we were assured that this virus would soon work its way out
of her system.

48 hours later, today, on the 8th day of fever, I
have come to you, Mr. Holmes, for I am truly at my wit’s end.

“I asked her about the red marks and the mother stated that
perhaps they were flea bites from a neighbors cat that occasionally wondered
into their yard. The patient is
up-to-date on all immunizations and quite up to par on her growth charts and
developmental milestones.”

“Perhaps, Holmes,” I suggested, “you might want to use a bit
more tact when talking to parents of small children.”

“What in the world for?” he seemed incredulous, “the world
is a difficult and deadly place, Watson.
The sooner a parent and child realize that this is a fact, the
better.” Despite his harsh words, he
ministered to the distressed mother with a gentleness that surprised me.

“My dear lady,” he spoke with more kindness, “allow me to
share my logic with you and my hope for your daughter’s complete recovery. First, Kawasaki Disease is a challenge for
the finest of medical detectives. We
don’t understand what causes it and your daughter has a remarkable lack of
clinical symptoms that clue us to the diagnosis. She has no conjunctivitis, no mucosal
membrane involvement, no enlarged lymph nodes, no rash, and no hand and feet
changes. She does however, have a
compelling number of suggestive laboratory findings: the WBC count above
15,000, the low albumin, the sky-high sed rate, and a mild anemia. We must begin the high-dose aspirin now and
the IV immunoglobulin to prevent devastating coronary aneurysms. We are beginning treatment on day 8 of her
fever, which means we have every expectation of success in her case.

DISCUSSION

We started the IVIG 2mg/kg over 12 hours right away on our
17 month old female, along with aspirin 80mg/kg qid. She was afebrile within 8 hours, active,
hydrated, and happy. We seemed to be on
track. Then, at midnight on Day #9 of
illness, she spiked a fever to 102 degrees F.

“Holmes,” I warned him, “I have bad news on our little
client. She has spiked fevers, despite
our diagnosis and treatment. Have we
gone wrong in our reasoning? What if we
missed meningitis? What if we missed
mononucleosis or Typhus?

“Calm yourself, Watson, let us look at the facts and only
the facts, rather than working ourselves into a lather over if, if, ifs. Let us consider meningitis, for it is true
that we could be criticized for not doing a lumbar puncture on the day of
admission. However, the cold fact is
that a child with a week of fever due to bacterial meningitis would hardly be
bouncing about the room like a proverbial Tigger, as our patient has done
throughout this illness. And why would
the WBC count be going down if we were missing a serious bacterial
infection? And why in the world would
her platelet count be climbing rather than falling due to marrow suppression in
the face of overwhelming sepsis.

What about mononucleosis?
Her age definitely portends against this diagnosis, but so does her
lymphopenia. By the way, I had a
monospot run just for you, and it was negative as was the smear review for
atypical lymphocytes.

Typhus? A good thought,
given the mother’s worry about flea bites from a vagabond kitten. However, the lack of rash, relative
neutropenia, hyponatremia, thrombocytopenia, and hepatitis makes Typhus less
likely.

But, a good clinician looks not just to eliminate the other
possibilities, but to confirm what he believes to be the most likely cause of
the illness. A little digging revealed
that Kawasaki patients often have a lymphopenia, a platelet count that climbs,
beginning on day 8 of illness, and a fever within 36 hours of the
administration of IVIG. Our little
client fit these criteria like a glove.
Watson, we are still on the right track, have no fear.”

CONCLUSION

Our little client had no further fever spikes after that 36
hour mark. Her echocardiogram revealed
clean coronaries, no ectasia, and no aneurysms.
The high dose aspirin was stopped when she had been afebrile for 48
hours and low dose aspirin at 5 mg/kg was started. No repeat IVIG was needed, nor indicated.

She left the hospital a whole and happy little girl, with a
very pleased mother and father.

We will continue the low dose aspirin until her sed rate and
her platelet count drop into the normal range.
We expect that should take 4-6 weeks, given her remarkable recovery both
in fever and in her laboratory testing to date.

“Holmes,” I asked, “what about the UTI?”

“Elementary Watson,” he smiled, “true, true and
unrelated. Imagine if she had an
obviously abnormal urine on day #8 of the illness. We might have dismissed the issue as a mere UTI. Antibiotics would not have protected her
heart and we would have missed our window to administer the IVIG and prevent
lifelong debility or worse. No Watson, I
believe that the Living God presents us with puzzle pieces that complete a
perfect picture and protects us from distractions, if we but stay alert and
awake. And now,” he took up his violin,
“I will attempt to keep you awake you with a little atypical violin composition
of my own.”